Bedless Psychiatry and A Recipe for Remaining Bedless

There is no better marker of the rickety psychiatric infrastructure in the USA than the lack of psychiatric beds.  A close second is how those beds are utilized to basically run patients in an out to maximize hospital profits. It seems like I have said it a thousand times on this blog but I will say it again - hospitals make money by getting psychiatric patients out in advance of the diagnosis related group (DRG) time limit.  These days that it is about 3-4 days. If management believes that the psychiatrist is not discharging people fast enough - they will turn up the heat on them to do so by using either a designated case manager or somebody who sits in team meetings and reports that psychiatrist to his or her superiors if the patients are not out by a maximum of about 6 days.

There are huge problems with that business approach to psychiatric care.  The first is patient complexity. Severe psychiatric disorders place people at risk for significant medical problems and often psychiatric care cannot proceed until those medical problems are stabilized.  During my career for example I had terminal cancer patients and patients with uncontrolled diabetes mellitus and hypertension admitted directly to my care because they had a major psychiatric disorder.  Substance  use disorders complicate at least half of the admissions and psychiatric care typically has to wait until a patient is detoxified from an intoxicant.  Very ill patients with schizophrenia and mood disorders who received outpatient treatment cannot be treated and stabilized in 4-6 days.  Specific problems like suicide risk and delirium often take many weeks of care.  Although brief stays can be useful in the case of event or intoxicant related crises the length of stay on psychiatric units is basically an arbitrary number of days determined by bean counters rather than doctors. They do no reflect clinical reality.

That brings me to the commentary by Sisti, Sinclair, and Sharfstein (1).  They lost me then they had me and then they lost me completely.  My first criticism is the title "Bedless Psychiatry-Rebuilding Behavioral Health Service Capacity."  Ironic that the authors use the managed care buzzword "behavioral health" to suggest that the bed crisis can be addressed by the same carpetbaggers that designed the current system.  I can appreciate a political turn of a phrase as well as the next rhetorician, but in the case it falls very flat.  The only way to address the bed crisis and the destruction of the mental health care infrastructure in this country is to get rid of managed care and all of their buzzwords.  There is no way that companies paid well for rationing care and kicking unstable people out of psychiatric hospitals are going to solve that problem.

From there the authors do an adequate job of describing the problem of a sharp drop in bed capacity in addition to the absurdly short lengths of stay.  They depend on data that may have another agenda.  In a recent post in this blog, I looked at the drop in state hospitals beds in Minnesota and the Medical Directors commentary on why that will never be reversed.  The same organization that authored the report used by the authors to describe the drop in beds (National Association of State Mental Health Program Directors (NASMHPD) is on record stating that "Building more inpatient bed capacity to meet demand is unsustainable".  State Mental Health Program Directors are all accountable to state politicians and generally run state mental health programs like managed care companies do.  They ration services and limit access to treatment. It is cost effective from their perspective to leave large blocks of people untreated. Better yet put them in jail and give them a baloney sandwich everyday instead of the à la carte fare that medical and surgical patients have come to expect in customer satisfaction based hospitals.  This conflict of interest and lack of interest in looking at whether bed capacities are too low is a bias that any reader of the report should be aware of.   They also consider OECD data and suggest that psychiatric bed capacity in the USA is 4th from the lowest bed capacity in the countries studied.

They go on to discuss the "types" of beds  and suggest that the notion that bed capacity may be too abstract.  They favor bed descriptions based on the function of the unit that they reside on - forensic, acute care, intermediate, and long term care.  They discuss beds in the grey zones between corrections and mental health.  For example in my discussion of the Minnesota situation, I did not include beds operated by the Minnesota Sex Offender Program (MSOP).  That program houses 726 clients at two large facilities or about three times the state bed capacity for all of the committed patients with mental illness in the state.  In a bizarre end run around psychiatry, sex offenders in the state are essentially granted mental illness status.  This occurs in order to allow the state to indefinitely commit them.  MSOP clients are essentially never discharged while committed patients back up and crowd local hospital psychiatric units and shut them to new admissions while they are waiting to be transferred into the state hospital system.  The argument about no new beds at the state level does not apply to sex offenders.

The authors close by saying the concept of a psychiatric "bed" may need to be "jettisoned" in order to more accurately address the needs of patients and system capacity.  They end with the idea that "targeted payment reforms" are necessary to increase psychiatric bed capacity.  I think that they have it wrong on both accounts.  We have had 30 years of "incentives" that really are not incentives.  The DRG payment itself was allegedly a payment for what was the average amount of care for a particular diagnosis.  Instead, it became a way that managed care companies could game the system while they rationed care.  It may not be as easy to determine (another bean counter bias) - but looking at the flow though systems and where services are short is a better idea.  Classic examples are outpatient psychiatrists who are not able to refer one of their outpatients to an inpatient unit in the same system for purposes of detox, electroconvulsive therapy, or stabilization.  Whenever that happens it should be taken as a sign that health plan needs to improve their bed capacity.

Bed quality is as least as important as bed inventory.  Beds are worth less if there are problems with the physical structure or staffing problems.  Beds are worth less if a therapeutic environment cannot be maintained. Beds that can contain aggressive behavior are generally at a premium because fewer people can work in that setting. In every state there are only a few psychiatric units that will address aggression as a psychiatric problem.  Specialty units to treat depression, bipolar disorder, schizophrenia, substance use in addition to mental illnesses, or medically ill psychiatric patients are rare.  There appears to be no interest in either the quality or specialty side.  DRG payments create an incentive to get people out as soon as possible and provide the lowest level of quality.

A very basic comparison with any systems of high quality beds that address the medical problem with state of the art care is instructive. Any middle aged person in the US who presents to the emergency department with chest pain who has cardiac risk factors will be admitted to a telemetry unit, get the necessary blood testing, and (if all of those tests are negative) will probably get an echocardiogram and cardiac stress test before they leave the next day. That same person presenting to the emergency department with hallucinations or mania or severe depression or delusions will only be admitted unless they are determined to be "dangerous".  The standard definition of dangerousness being "imminent risk of harm to yourself or others."  Dangerousness is the managed care approach to psychiatric hospitalizations.  It contaminates emergency assessment and it contaminates what happens on the inpatient side.  When the overriding treatment dimension is dangerousness - inpatient units become holding tanks where nothing therapeutic occurs. Patients sit around and look at one another all day long waiting for someone to proclaim that they are no longer dangerous - so they can be discharged.  Beds that operate under this punitive model should probably not be counted. 

The authors' commentary seems to continue the same policy wonk approach that has contaminated practically all medical journals - basically a number of administrators sitting around and speculating.  Unfortunately we know that a lot of bad ideas get started this way. We also know that hypotheticals and incentives have have been the order of the day for a generation and that very process knocked out bed capacity and led to all of this low quality care.

To improve the bed capacity it will take a psychiatrist who is aware of the problems and how they can be addressed in each state.  Being on the ground as the inpatient beds and any quality they had were rationed away would be a plus.  Knowing how to build increased capacity and quality is the best possible approach. 


George Dawson, MD, DFAPA



References:

1:  Sisti DA, Sinclair EA, Sharfstein SS. Bedless Psychiatry—Rebuilding Behavioral Health Service Capacity. JAMA Psychiatry. Published online March 14, 2018. doi:10.1001/jamapsychiatry.2018.0219

Graphics Credit:

The above picture of an abandoned state hospital bed is downloaded from Shutterstock per their standard licensing agreement.

Is Mental Health Legislation Really The Joke That I Think It Is?

The above graphic is a headline search of mental health parity going back to 2004.  I was in the thick of things from 2009-2012 as the transitioning President of a District Branch of the American Psychiatric Association - the Minnesota Psychiatric Society.  Not that it gave me the inside track on anything.  I think officers in district branches spend most of their time trying to get members motivated to do something.  My strategy was basically to approach things in the way I do on this blog.  I don't think that is was any more or less successful than the dialogue promoters, but at one point some people became uncomfortable when I suggested that one of the hospitals could have been managed better.  It was apparent to me at that time that professional organizations do not tolerate disagreement very well.  As far as I can tell, there can be no real changes in organizations without disagreement and disagreement should be expected anytime there are people who want to talk endlessly and people who want action.  On the other hand nobody has to take it personally.  That may not be possible in Minnesota or in professional organizations.  I have previously referred to it here as the "big tent" approach where multiple goals are tolerated even some that conflict with the overall goals and ethics  of the organization.  An example would be prior authorization of medications.  The vast majority of members find it extremely intrusive and a waste of their time, but the members who are executives in managed care organizations do not.  Accepting both of those positions is a tacit acceptance of prior authorization while working with the members to change it.  How do you think that will work out?

Parity or equal coverage for mental illness and physical illness was a legislative initiative of two U.S. Senators Paul Wellstone and Peter Domenici.  Both had personal experience with the problem having family members with severe mental illness.    That personal experience remains critical in the political and cultural landscape.  There are still plenty of people pushing the "myth of mental illness" fallacies.  Some have moved on to just blame psychiatrists.  People with experience recognize those arguments for what they really are and can try to proceed with real solutions.  I never met Paul Wellstone, but I liked him a lot.  He was one of a handful of US Senators who voted against authorizing the invasion of Iraq based on the flawed weapons of mass destruction argument.  He was vilified by some for the vote and referred to as an ultra-liberal.  That is a glib characterization during an era where there are no liberals.  In Minnesota he was widely known as a populist.  People perceived him as a common man who cared about the common people.  He was tragically killed in a in a plane crash in northern Minnesota in 2002 while campaigning for his fourth term in the Senate.  Senator Domenici retired from the Senate in 2009, after the longest tenure at that position by anyone from the state of New Mexico.  My guess is that the final form of this bill and the way it is implemented was not the intent of either of these Senators.

I read through several iterations of their bill until it became The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).  All of those versions are available on the Congressional web sites, but the factsheet is available from CMS.  It should be fairly obvious by any casual read of the factsheet that there are so many exceptions and vagaries associated with this law that it would not take the insurance industry and their government affiliates long to shred it.  I pointed this out at the APA 2011 Annual Meeting in Hawaii.  There was a meeting about how the MHPAEA was going to revolutionize the care of people with addictions.  A prominent psychiatrist and government official was scheduled to be there to explain how this was going to happen.  At the time, the impact of the law was not apparent on any of the acute care services where I was working.  At the meeting after listening to an overenthusiastic presenter explain how funding all of these programs were going to greatly increase bed capacity and services for all, I asked the simple question: "What would prevent any managed care company from providing a screening test and calling that assessment and treatment?"  The answer was "Nothing would prevent that."  No elaboration.  No discussion of how employers can just opt out of mental health and substance use treatment.

That introduction allows me to flash forward to the current time.  I was recently interested in referral for an acute psychiatric hospitalization in the Twin Cities - a metropolitan area of 3.8 million people.  According to a 2007 state report there were a total of 563 acute care beds for that area or 14.8 beds per 100,000 population.  According to the Organisation for Economic Co-operation and Development (OECD), the US ranks about 30th of 35 ranked industrial countries in terms of psychiatric beds per 100,000 population and the Minnesota metro is significantly below the US average of 25/100,000.   Based on those factors it should not be surprising that I was advised that there were no available beds and that the emergency department we could refer to had a 30 hour wait for assessments.

Compare that to Cardiology services in the same area.  Any middle-aged person (or younger) with chest pain would be immediately admitted to a coronary care unit or telemetry and have a standard evaluation completed even if they were discharged or undergo emergency catheterization and angioplasty/stenting.   I have never heard of a wait for acute Cardiology services.  I have never heard of a 30 hour wait in the emergency department for Cardiology services.   My point here is that the MHPAEA or parity legislation has done exactly nothing for the availability of acute psychiatric services.  These same numbers and waiting times in the ED have been there for the past 15 years.  There is no parity as long as there is no equal funding, and mental health services are funded at a fraction of what Cardiology services are.  Walk through any modern Cardiology Department or Heart Hospital and ask yourself: "Where are the equivalent psychiatric or mental health services?"  There are a few exceptions but generally not many and even then, a new facility is still managed by rationing strategies that result in people being discharged with inadequate plans and before their problems are completely addressed.  Inpatient psychiatric services are in effect behind a firewall and accessible only through the bottleneck in the ED.

The grim picture of acute care mental health services is only exceeded by the state of acute care addiction services.  As early as 1988, I was being advised by managed care companies that I could not detoxify patients with alcohol dependence on inpatient psychiatric units,  even if they had significant psychiatric comorbidity like suicidal ideation and depression.  The picture has gotten progressively worse since then.  It is common practice these days to send alcohol dependent people home with benzodiazepines and expect them to manage their own detox.  The lack of functional detoxification services keeps many people in the cycle of addiction to benzodiazepines, opioids and alcohol.

Confirmation of my skepticism about parity came in the form of the Mental Health Reform Act of 2015.  It is also a bipartisan bill introduced by Senators Bill Cassidy (R-Louisiana) and Chris Murphy (D-Connecticut).   There are House and Senate versions.  Both establish a new assistant secretary position for mental health and substance use disorders under the Department of Health and Human Services (HHS).   The fate of the Substance Abuse and Mental Health Services Administration (SAMHSA) hangs in the balance and getting rid of this highly flawed agency should be a priority.  SAMHSA has been the lead agency for mental health during this time of no parity and has not said anything about it.  The remaining description of the bill has to do with education people about HIPAA (do we really need that?) and insurance company accountability for a lack of parity.  The fanfare for this bill including praise from the APA is the exact same way the parity legislation started.  It should be evidence to every American by now that Congress is really interested in appearing to do something and appearing to want reform rather than getting the job done.

I don't think that there is anyone in Washington who knows the meaning of the word reform.  Until politicians everywhere realize that mental health services and substance use services have been an easy way for health care companies to make money by denying reasonable services nothing will happen.   It would help legislators to realize that they also have the highly flawed idea that managed care actually saves money and it is a conflict of interest for them to continue to promote this middle man on that basis.  I am not holding my breath, but it should be obvious that when a reform bill happens every 7 years, and there are still 30 hour emergency department waits and no acute care beds for admissions - there is no parity and there has been no reform.

George Dawson, MD, DFAPA





         

Happy Labor Day IV

This is my fourtth Labor Day writing this blog and it is my custom to summarize the work environment for physicians like I did in Happy Labor Day I, II, and III.  Things have not improved very much and there was a timely piece by an anonymous physician filed on another blog entitled Confessions of a Burnt Out Physician.  That post is full of anecdotes about physicians being managed like production workers and to the point of not even having an adequate work space to conduct work that requires focus and confidentiality.  Another key element of managing physicians is to make sure that their days and nights are filled with the modern equivalent of paperwork - e-mails and charting that is read by nobody except the occasional coding and billing staff.  If that is not demoralizing enough, there are always the suggestions that physicians are not doing enough, even though they are easily in the hospital for 4 or 5 hours after all of the business people are long gone.  This can all be handled masterfully.  As an example, the RVU productivity system was in many cases introduced to physicians as a system of "fairness".  That is - the idea that everyone has to pull their own weight.  That works very well in any environment of competitive physicians.  It was dovetailed in nicely with multimillion dollar lawsuits by the Department of Justice that were based on charting.  Now physicians could be fined or imprisoned if their documentation was not up to snuff.  And of course the Department of Justice wanted every physician in this country to know that any discussion of fees was a potential antitrust offense.  When all of that business rhetoric had settled out, the only things that really changed was how easily physicians could be manipulated and overworked while their professionalism was completely ignored.  Apparently none of us knew how to work or act before managed care came along.

There have been some additional business innovations in the last year to make physician's lives even more difficult.  I read another blog recently where the topic of physician managers affiliated with Big Pharma were desired to bring money into departments and how that and key opinion leaders (KOLs) from that field was a key corrupting influence in medicine and psychiatry.  That influence is trivial compared with the business influences on medicine and their adverse effects.  Excellent clinicians, teachers and researchers now need to get an MBA before they are considered as a department head.  A managerial class that is progressively less competent to manage may be an acceptable business standard but it seems like an extravagance in medicine and one that has cost us hundreds billions of dollars and untold unnecessary work for physicians.

Furthermore, we know what works in terms of physician management.  I worked in tens of departments where the department head was a physician who was in that position because of skills pertaining to clinical care, teaching and research.  That doesn't mean that they were necessarily easy to get along with, but in teaching institutions their skill set was on display every day.  That model transitioned to one where a physician and an administrator of some type both co-lead the department.  The physician leader was still affiliated with physicians in the field at that point and could feel their pain.  The next step was removing any physician with those alliances from an administrative position.  In many cases, this meant people who had no hesitation to manipulate physicians either by a "It's my way of the highway" attitude,  making the environment so hostile that they forced selected dissenting physicians to quit, or after pretending that the physicians had some input (usually through endless mind-numbing meetings about the business) simply telling them that no matter what their opinion was - this was what would be happening.  Throughout the process there was an endless stream of "Change is good", "Cost effectiveness", and "Managed care friendly" propaganda.  But it didn't stop there.  Managed care run institutions have an entire cadre of case managers whose primary job is to "manage" physicians and make sure they are discharging people according to the companies proprietary standards.  If there are any disagreements that low level administrator can easily go up the change of command to get decisions in their favor or identify physicians who are not in lock step with the company.  Everywhere within these organizations there are rules about identifying "disruptive physicians" and penalizing them.  I am not talking about doctors throwing scalpels across the operating room.  The threshold can be so low these days that a "disruptive physician" is anyone who gets into it with an administrator for any reason, including legitimate disagreements.

The effect on the psychological environment of physicians has been corrosive.  Within a generation we have gone from a training environment where medical students and residents could identify with senior physicians who embodied professionalism and an intellectual approach to medicine to managed care employees who use a business approach.  Instead of rounding on patients and learning the importance of medicine as a life-long intellectual pursuit, trainees are focused on the business manager's pursuit of getting patients out of the hospital so that corporate America can keep making money by easily beating the fixed reimbursement scheme set up by the government.   The business rationalization has always been "of course we need to make money to keep the doors open", but that never addresses the trade-offs.  In this case the trade-off is no relationship or plan to assist the patient.  In the case of patients with psychiatric disorders, there are inadequate inpatient and outpatient services, both due to business rationing to maintain profits in a rationed and cost-shifted world.  In many cases health care systems have carried these plans to their absurd conclusion - just close any inpatient beds, close the outpatient clinics, and hope that some taxpayer funded clinic or jail can pick up the slack.  The typical health care manager has an endless stream of bad ideas.

Are there any bright lights on the horizon?  I think that there are.  I would count the movements against the medical specialty boards and the proposed maintenance of certification (MOC) programs.  It is very positive that physicians are standing up and saying that they are unnecessary, not evidence based, and a tremendous waste of time, money, and resources.  More importantly all of that stress falls squarely on overworked physicians.  There is now at least one parallel certification organization that depends primarily on initial board certification and then continuing medical education courses - the historical standard.  It will take a significant commitment, especially from younger physicians to keep this movement alive because it is just a matter of time before credentialing committees for clinics and hospitals will be putting the squeeze on their physicians to use the labor intensive MOC programs.  There is also the question of medical boards.  Will they require MOC for maintenance of licensure (MOL)?  Only time will tell, but like all things American - the bet is on the oligarchs and that currently is everyone making a lot of money out of managing physicians.  At some level that includes professional organizations populated by members who are very friendly to the business world.  If anyone doubts the benefits to professional organizations, just visit the American Psychiatric Associations Learning Center and the MOC offerings.  If the monopoly can be broken, it suggests that physicians may have the ability to counter the business and government strategies that keep what is basically an anti-physician system afloat.  Business strategies have nothing to do with the practice of medicine.

Another bright light that I neglected to comment on initially is the young psychiatrists going into private practice.  At first I was reluctant to endorse this idea, primarily because it contrasts so starkly with my experience in community psychiatry, acute care psychiatry, and general hospital psychiatry.  I was concerned that there would not be enough psychiatric expertise to care for very ill people.  But in conversations with many young colleagues they are some of the brightest, happiest, and enthusiastic physicians that I have seen.  The reason I am given by these docs is that they decide who they are going to see and what their schedule is and not some administrator.  They decide what their clinic policies are and not some administrator.  Some of them have worked in managed care settings and had the courage to walk away after the standard "performance evaluation", especially when it had become an exercise in a loyalty oath to the company and trying to dredge up anonymous critical remarks from coworkers.  My opinion on this private practice trend is that it is a good one.  Any person consulting these folks is going to get recommendations based on quality psychiatric care and not proprietary managed care guidelines.  They will also be talking with a psychiatrist who has not seen ten other people before them and one who has the energy to focus on their problems and possible solutions.  Some of these private physicians also spend days in community mental health centers and on community support teams - treating patients with severe problems.      

So my fourth Labor Day message is slightly brighter than the last three, but not much.   I have to say that there are a few of us around yet who know exactly what happened and what is possible -  and I feel your pain.  If you feel up to it post your anonymous story here.


George Dawson, MD, DFAPA

Minnesota Finally Rejects Managed Care

In a rather stunning reversal of thirty years of public policy, the Minnesota Legislature voted last week to fund for a "network of small treatment centers" to compensate for all of those years of rationing.  The details are still vague  but it is described in the StarTribune article by Serres as a "network of small treatment centers, to be built across the state, anchoring a broad package of preventive services so children don't end up in emergency rooms or inpatient psychiatric wards where many of them are discharged prematurely for a lack of beds."  The funding is about $13 million for 2 years and $6.6 million "to create a network of 30-bed treatment centers for children with highly aggressive or self-injurious behaviors, who are often turned away from hospital inpatient units."  Political speak is evident in that sentence.  I can't imagine that $6.6 million or even $19.6 million gets you a lot of 30-bed treatment centers.  Later in the article a total new bed capacity is described as 150.

The author of the article is oblivious to how this all happened in the first place.  Was Minnesota an idyllic place with no mental illness in the first place?  Did the problem arise because an epidemic of mental illness?  Absolutely not.  Thirty years ago, the state had more bed capacity and more treatment options for both children and adults with mental illness.  Minnesota is a state with massive managed care presence and those managed care companies currently run all of the acute care psychiatric beds in the state - for both children and adults.  Once managed care companies learned that they could deny hospitalizations based on some fictional "dangerousness" criterion and otherwise ration psychiatric services at multiple levels there was - in effect - no rational psychiatric care.  As I have posted on this blog many times, people are discharged from hospitals in a few days essentially without treatment, treatment units are chaotic without a therapeutic environment, people who require medical detoxification form drugs and alcohol are generally out of luck, and it creates and ongoing demand on emergency departments and correctional facilities.  All it took was getting these practices embedded in the state statutes and setting up a cursory review of complaints against managed care companies at the state level to seal the deal.  The reporter in this case makes it seem like the Minnesota Legislature and a "bipartisan coalition of lawmakers" are solving a problem.  This is a problem they created in the first place and I will believe in a solution when I see it.

I have some first hand knowledge of the problem with children's services from my contact with child psychiatrists around the state.  Their experiences are echoed in the story in this article of what happens when your child is out of control and nobody is willing to help.  The family in this case describes a 17 year old boy with severe mood problems, aggressive thoughts and thoughts of self harm.   He was hospitalized 6 times and discharged in a heavily medicated state.  He was turned down by 30 residential facilities before being accepted by an out of state facility.   His parents describe themselves in a "perpetual state of anxiety" trying to manage all of these scenarios.  But the most incredible line in the article:

"For years, children who exhibit highly aggressive or violent behavior in Minnesota have been forced to drift from one short term hospital to the next, often returning to their families heavily medicated but with their illnesses largely untreated."

This is not surprising to any psychiatrist.  This is the end product of managed care rationing and it occurs whether the patient is a child or an adult.  It happens when businesses and governments collude in providing some bastardized version of psychiatric care.  It happens when psychiatrists in this case are ignored.  When state officials ignore psychiatrists. When psychiatrists who are trained to treat aggressive and violent behaviors are not allowed to do their jobs.  After all, why would anyone with aggressive behavior because of a mental illness be turned away from a psychiatric unit?  Aggressive and suicidal behavior are the main reasons that psychiatrists exist today.  It is what we do.  Let us do our jobs.

So far this is one small victory for children's mental health advocates and my cap is tipped to them.  But to reverse more of the problem we need to acknowledge what it is and it is managed care or more specifically their marketing word for mental illness - behavioral health.

Let's get rid of it entirely.

   
George Dawson, MD, DFAPA

Reference:

Chris Serres.  Facing chronic shortages, Minnesota's mental health system gets a boost.  Minneapolis Star Tribune, May 29.  


Supplementary 1:  The image used for this post is of Dexter Asylum attributed to Lawrence E. Tilley [Public domain], via Wikimedia Commons.  The original image was Photoshopped with a graphic pen filter.

Supplementary 2:  For a detailed post on some of what happened try this.

A Return To Asylums Will Not Stop The Rationing

An article was published in the JAMA recently where three ethicists argue for the return of asylum care.  It has become an expected flash point for the antipsychiatry movement as well as some psychiatrists who still think that the word asylum has some meaning.  I thought I would add a more realistic opinion and solution.  I refer readers to the original article or many that I have written here about the reduction in bed capacity in long term psychiatric care.  The reductions are indisputable and well documented.  I am more interested in elucidating the mechanisms behind this reduction and the lack of effective care in the remaining community hospital beds.  The authors allude to the underlying dynamics as captured in the sentence "For the past 60 years or more, social, political, and economic forces coalesced to move severely mentally ill patients out of mental hospitals."  They discuss the well known euphemism for incarcerating psychiatric patients or "transinstitutionalization" and rotating the chronically mentally ill in and out of emergency departments.

The authors even go so far as pointing out the bloated estimated inpatient costs for care in Michigan at $260,000/year/patient and Washington, DC at $328,000/year/patient.   For comparison they include a state of the art facility the Worcester Recovery Center and Hospital that has 320 beds at a cost of $60 million per year or or $187,500/bed/year.  It is difficult to figure out why what may arguably be the best public hospital in the United States has the lowest cost of care for what may be more comprehensive services.  But that is part of the problem.  Most of these institutions are managed by human services agencies through the states and the real fiscal status is always difficult to ascertain.  State and business accounting frequently provides calculations for bed or per patient rates that seem to include unrealistic estimates of overhead costs (often for subpar facilities).  The administration of many of these facilities also seems to depend on restricting psychiatric care at several levels.  In many cases the managed care concept of "medication management" or a "med check" mentality is applied, often with the overall plan of replacing psychiatrists with "prescribers".  Any notion of quality is trumped by a managed care notion of "cost-effectiveness" that typically includes removing psychiatrists from management positions and delegating policy and management at the institutional level to people with no training in psychiatry.

The authors accurately describe the problems of severe mental illnesses.  People have very complex neuropsychiatric disorders and will either not be getting well soon or will never recover enough functioning to do well in any community setting.  They were some of the first victims of "medical necessity" criteria.  I was a Peer Review Organization (PRO) reviewer for Medicare hospitalizations in the states of Minnesota and Wisconsin in the 1980s and 1990s.  For at least part of that time I was sent boxes of medical records from state hospitals for review.  If I looked the the records and decided the patient should continue to be hospitalized, I would get a call from the Medical Director of the PRO suggesting that I should consider the medical necessity criteria.  In the case of long term care, that meant that the patient was "stable" meaning that I would not expect them to change significantly with additional treatment.  If I could say that, the hospital was notified that the patient did not meet criteria for continued long term hospitalization and they needed to be discharged.  In fact, it was very likely that although they were not changing at a rapid enough pace, they would still present formidable problems for community placement.  It may be impossible to discharge them.  In many cases discharge resulted in almost immediate readmission to an acute care hospital and the cycle emergency department to brief hospital admission to homelessness to jail or readmission occurred.  At least until the person was sent back to the state hospital.

In her opinion piece, Dr. Montross suggests that these patients have been abandoned in the name of autonomy or  treating people in the so-called "least restrictive alternative."  That seems at odds with frequent sustained incarcerations for minor and in some cases trivial offenses.  What is really going on here and why do people continue to ignore it?  I have analyzed the problem many times and it is apparently so institutionalized at this point that nobody sees it as a problem anymore. The problem that I continue to point it out is managed care and all of the rationing mechanisms that they employ.  The very first one in the paragraph above is the so-called medical necessity criteria.  Any managed care company physician reviewer can deny care based on their own proprietary guidelines or a purely arbitrary and subjective interpretations of those guidelines.  Managed care companies can harass physicians with mountains of unnecessary paperwork and deny payment or demand payment back based on more subjective interpretations.  Even more problematic, states have incorporated some of these same management techniques and almost uniformly have completely abandoned quality in favor of "cost-effective" care which is quite frankly - care on the cheap.

The end result of all of this cost cutting, rationing, and insurance company profiteering at the expense of patients with mental illness or substance use problems is extremely poor quality care.  One of the authors suggests longer inpatient treatment may be the solution.  Right now practically every psychiatric hospital does their best to get patients discharged in 5 days or less.  Outpatient psychiatrists see patients who have not been stabilized after a 5 day admission.  That is business as usual in acute care psychiatric hospitals.  If that discharged patient makes it to an out patient clinic, they are seen for 10 - 15 minutes in a medication management visit (another fabrication of the managed care industry and the US government) and if they are lucky they discuss the medication and whether it is effective for symptoms or causing side effects.  The problem is that there are important areas in the patients life - like their cognition and social behavior, that are never discussed or evaluated in any productive way.  Very few patients with severe mental disorders receive any kind of psychotherapy despite the evidence it is useful to them.

Putting all of these problems back into the asylum will have predictable results.  The medication management mentality is basically now inside the walls of an institution. There is no enlightened, research driven treatment that addresses all of the problems that the person has.  The asylum is typically administered by a bureaucrat, bound by the same arbitrary budgeting that comes down from the Governor's office.  Across the board spending cuts by a certain percentage and no adjustments when the cash flow is positive.  Money "saved" on asylum care transferred to the state's general fund and used to build roads or whatever was stated in campaign promises.  Suddenly the asylum is an overcrowded bottleneck due to cost shifting by every county in the state who does not want provide services for serious mental illnesses.

The alternative?  How about doing things the right way for once.  We seem to have people who recognize that mental illnesses are not going away, that the current care is atrocious and inhumane, and that it is time to do something about it.  Estimates for the number of people in each state with severe mental illnesses are out there.  Consistent reasonable funding is necessary.  That includes the state, but also it is time to not allow managed care companies to dodge these costs and transfer them to the tax payers.  Finally, it it time to eliminate stakeholder meetings and develop systems of care for the people who it matters the most to - patients, families, psychiatrists, and the other mental health and medical professionals involved in providing this level of care.

Without those conversations, an asylum is just a poorly managed building.    




George Dawson, MD, DFAPA



References:

1: Sisti DA, Segal AG, Emanuel EJ. Improving long-term psychiatric care: bringback the asylum. JAMA. 2015 Jan 20;313(3):243-4. doi: 10.1001/jama.2014.16088.  PubMed PMID: 25602990.

2:  Christine Montross.  The Modern Asylum.  New York Times February 18, 2015.

Welcome To 1974

A colleague forwarded me a link to a newspaper article today about the latest Twin Cities managed care innovations for treating people with severe mental illnesses.  It had nothing to do with managed care companies trying to save money or avoid penalties.  Like most of these stories in the press there is a heavy human interest focus.  The treatment details are given of a man with schizophrenia and depression who is benefitting "from a fundamental shift in the way hospitals and health plans treat people with severe mental illnesses."  The author goes on to explain how social services including housing, transportation, and job training are being implemented prior to discharge and coordinated by social workers.   The article suggests that the reasons for this are two fold - to prevent the "revolving door" of readmissions to the hospital and a new Medicare penalty for readmissions during the first  30 days of discharge from a hospital.  The programs at a number of Twin cities hospitals are described.  The Minnesota law requiring admission to a psychiatric hospital from a jail within 48 hours of commitment is also cited as a complicating factor in the large group of patients that have no stable housing, no medical or psychiatric care, substance use problems and who continue to rotate in and out of psychiatric hospitals.  One of the managed care administrators describes it as a "sea change".

It turns out the "sea change" occurred in 1974.  It occurred in Wisconsin and not Minnesota.  That was the year that Len Stein, MD and a group of dedicated clinicians came up with the idea that patient with severe mental illnesses could be maintained outside of hospitals as long as they were provided with appropriate housing, support, and in some cases vocational services.  I know because I trained under Dr. Stein.  He was a personal supervisor and I did a training rotation at the Dane County Mental Health Center.  I can still remember the slide from his community psychiatry presentation that showed the overcrowded conditions at the state hospital - one of the reasons behind the community psychiatry movement.  My training occurred about a decade later and at that time there were three  different models of care that all involved community support.  The most well-known of those models is Assertive Community Treatment or ACT.   I was well versed in these models and providing the necessary care and for the first three years out of training I was the medical director at a community mental health center and spent have of my time working with the community support team.  That team provided crisis services and support on a 24/7 basis to patients with severe mental illnesses.  That was 30 years ago.

After the community mental health center,  I moved to the Twin Cities where I spent the next 23 years working in a metropolitan hospital primarily running an inpatient unit.  My focus for the first 10 years was trying to get people interested in community support services for patient we were discharging to the community.  At first, there was a patchwork of public health nursing and large housing units  with nursing supervision for our discharged patients.  But eventually there was nothing.  I was told point blank by various administrators that they really were not interested in hearing how things worked in Wisconsin.  They did things differently in Minnesota.  When I could no longer ask public health nurses to check on discharged patients - there was no help for them at all, except for an appointment to see a psychiatrist if they did not forget it.

That changed slightly when the state decided to shut down state hospital bed capacity and one of the psychiatrists there was able to get funding for ACT teams.  The rationale by the state was that some of the money to maintain state hospital beds would be diverted to the ACT teams.  Eventually that initiative increased but there was still not enough capacity.  There was still a large patient population without adequate housing or assistance.  The economic plight of many of these people was worsened by "spend down" provisions implemented by the state.  That meant that even though their income was 100% disability payments, they could be expected to pay up to 60% of it for medications.  That typically meant that the person went from poverty status to worse in order to continue recommended medications for their psychiatric disability.

Another problem was the bed situation and approaches that were being used to manage those beds.   That last half of my inpatient career, there was a continuous large pool of patients flooding Twin Cities emergency departments.  That resulted in initiatives to admit and discharge as soon as possible.  The entire focus of admissions and discharges was on "imminent dangerousness" even though there is no such legal standard.  It was a business standard of care.  Many people seeking admission because they were miserable realized this and said they were suicidal in order to get admitted.  Conversely, many people who still had significant problems and no good way to resolve them were discharge because they no longer met the "imminent dangerousness" criteria.  There were no quality approaches to care only a focus on rapid discharges of very ill people.

So I have to shake my head when I read about the "new" approach to treating mental illness and helping people to maintain themselves in the community.  There is really nothing here that was not done in Wisconsin nearly 40 years ago.  In the meantime there is a severely deteriorated infrastructure with fewer beds in both designated hospitals but also supportive housing.  I have significant doubts about the funding of these services since we know that managed care companies don't do community support services.  Who is paying for these social workers and psychologists?  Will they have to submit billing documents that are not practical to complete?  Even if they are being paid for by the state, that doesn't necessarily guarantee future funding.   At one point all of the public health nurses I was working with in the 1980s were told they could no longer see patients with psychiatric problems.  And what about the continued rationing by managed care companies now being made to look like it is innovation?

Welcome to 1974.

George Dawson, MD, DFAPA

Chris Serres.  Strategies shift for treating mental illnesses.  Star Tribune January 19, 2016.

Minnesota Continues A Flawed Approach To Serious Mental Illness And Aggression

I was shocked to see this article posted on a CBS web site.  I was shocked because I was completely unaware  that such a law existed.  I was shocked because Minnesota has fairly well documented problems in their state hospital system.  The state security hospital has had numerous problems with containing violence and aggression and there is no evidence that situation has been resolved.  There are very few specialized units in hospitals in the state that could potentially deal with the problems of violence and aggressive patients.  There has been no effort to modify the limited infrastructure in the state that has been the result of managed care-like rationing over the past 20 years.

The story is a lot more involved than suggested by the news article.  When I read it I contacted my state legislators and asked for clarification primarily by pointing me to where the "12 hour rule" existed in the State Statutes.  The Minnesota State Statutes are generally easy to search but I could not find it.  My state Senator got back to me and suggested that this is the rule in 253B.10 PROCEDURES UPON COMMITMENT.  Chapter 253 is the civil commitment statute and reading through this chapter suggests that transfers from jail to state mental hospitals have to be adjudicated as mentally ill by civil commitment.  Other pathways include being found not guilty by reason of mental illness, and for examination or determination of competency to proceed to trial.  Apart from the time constraint, that part of the statute does not materially alter patient flow to state hospitals.  The statute gets more interesting with the following subdivision:

Subd. 4. Private treatment.

Patients or other responsible persons are required to pay the necessary charges for patients committed or transferred to private treatment facilities. Private treatment facilities may not refuse to accept a committed person solely based on the person's court-ordered status. Insurers must provide treatment and services as ordered by the court under section 253B.045, subdivision 6, or as required under chapter 62M. 

Private facilities refuse to accept court ordered and committed patients all of the time just based on the fact that severe mental illness cannot be treated on an 8 day DRG payment that in reality is treated like a 4 or 5 day length of stay.

The article itself focuses on Anoka Metro Regional Treatment Center.  That is a state operated psychiatric facility just north of the Minneapolis-St. Paul area.  If the intent of the legislature is to alleviate crowding in jails, the writing of a statute will not do that.  If I had to estimate, the majority of inmates in county jails with significant mental illness and addiction problems are not committed and do not meet the forensic criteria suggested in the statute.  The article also illustrates the ambivalence that the state government has toward state run hospitals.  Not too long ago, the legislature wanted to close this hospital down.  Many states have adopted the managed care rationing model to mental illness.  They reasoned that the best way to "save" money is to close down state-run hospitals and clinics.  I have no doubt that the state would close it down if possible but it occupies too central a role in the civil commitment process.  There is instead a detailed political process to manage the hospital (see first reference).  That document is current, 114 pages long with 41 references to "jail" and 37 references to "aggression".  It acknowledges the role of the state in treating aggressive patients with mental illnesses. 

I have no way of knowing if any of the patients mentioned in this article requested transfer to a private hospital.  I would consider any hospital in the state that is outside of the state hospital system to be a private hospital because at this point they are all parts of private health care systems.  Only a fraction of community hospitals in the state have psychiatric units and a smaller portion of those are equipped to treat violent or aggressive patients.

I have tried to elaborate on this blog the type of structure necessary to treat people who are violent and aggressive as a result of mental illness. Any time that correctional populations are considered, the problem is more complicated than mental illness or not.  There are many individuals with sociopathy or personalities that are anti-authoritarian and with a tendency to criminal behavior.  At the extreme end a variant of psychopathy has been described where criminal tendencies, combined with a lack of empathy leads to an individual who is potentially more dangerous.  Those individuals often have a history of repeated violence against others and a pattern of planned violence as way of life.  The associated issues are that patients who are predominately personality disordered criminals are better taken care of within the correctional system.  Patients with primary mental illness who are incarcerated for non-violent crimes or violent crimes that occur only an episode of discrete mental illness are probably better treated in a mental health setting - especially if that is a continuation of their ongoing care.  Those statements are generally true because the personality disordered mentally ill will demonstrate a pattern of threatening other patients and staff with physical violence.  They may also exploit more vulnerable patients and try to intimidate them into giving them money, information, or personal favors that they can use to their advantage.  Those behaviors are goal driven, reinforced by a life of crime, and not likely to change as a result of any psychiatric intervention.

The article states that 146 inmates have been transferred from Minnesota jails to state hospitals since July 2013.  There is an eye witness account of what has occurred and a description of some of the injuries to staff including facial fractures and a torn shoulder tendon as the direct result of assaults on staff.  There is also the following statement from the affected staff person:

 And though she agrees there are other factors behind the rise in workplace injuries — a hesitance to use force against potentially abusive patients chief among them — she said she and her co-workers believe the 48-hour rule is largely responsible.

The issue of the use of physical force in psychiatric hospitals was also the primary cause of the upheaval in the previously cited problems at the Minnesota Security Hospital. A change in administration occurred to address the issue of patient injuries due to physical interventions. According to news reports that and the associated administrative measures were associated with an increase in staff injuries. We are left with the impression that there have been no effective interventions to prevent patient and staff injuries in state hospitals and the problem of aggression in these facilities has been poorly addressed. Organized psychiatry in the state has been silent on these issues.

The bottom line in this article is that it illustrates that Minnesota politicians and bureaucrats have no understanding of what is required to treat people with mental illness and aggressive behavior.  Their misunderstanding is significant and it occurs at multiple levels.  First, they have no understanding that the current system of mental health care is based on a system of rationing designed to provide minimal to no mental health care.  That all starts with hospital systems that have been rationed to the point that there are often no detectable changes in the mental health of the people admitted compared with the people discharged.  Psychiatric care in rationed hospitals is designed to limit treatment to a brief period or reimbursement.  Second, they have a track record of using mental health jargon to come up with their own diagnostic category of "sexual psychopaths" that can be used for indefinite confinement of sex offenders.  This categorization allows for diversion away from a correctional system that is apparently unable to confine sex offenders to the satisfaction of politicians and their constituents.  Third, the state managed security hospital has had a number of problems in the past few years including the mass resignation of psychiatry staff and an increasing number of injuries to hospital staff.  Fourth, Deputy Human Services Commissioner Anne Barry is quoted in the article. She was also quoted in previous articles about the Security Hospital. She attributes the problem to unintended consequences. To me that suggests a complete misunderstanding of psychiatric services in the state of Minnesota. Any psychiatrist in this state, especially if they work on an inpatient unit would be able to predict this problem. Commissioner Barry has also been quoted in the articles about the Security Hospital (see below)  Fifth, the direct quote by State Sen. Kathy Sheran also illustrates a misunderstanding of the problem. The idea that state hospitals are holding large numbers of people who don't need to be there is longstanding political rhetoric. In the absence of environments that can assist severely disabled individuals the default environments are hospitals. It is glib to say that people should no longer be a hospital when they have no safe place to live outside the of the hospital. As a reviewer of hospital admissions and lengths of stay, the presence of acute symptoms is typically used to mark who should be in a hospital. Chronic severe psychiatric disorders have a number of problems with cognition and functional capacity that lead to an inability to care for self independently of acute symptoms.  The associated political problem is a lack of funding for community based programs to resolve the problem.  As I have previously posted in many cases these community based programs that are inadequately equipped to contain aggression place both patients and staff at higher risk.

I qualify this post with the same qualifications I have put on previous posts on the topic on state run facilities.  The only source of information I have on this issue has been the press and legislative reports on mental health services in correctional facilities and at Anoka.  Media reporting of psychiatric issues and services leaves a lot to be desired and typically vacillates between blaming psychiatrists for all of the problems and tragic cases that result from a lack of services.  The only corroboration in this article seems to be the reaction of state politicians to it.  We have seen similar reactions to these issues in the press.  Unless there are some outright denials about the scope of the problem, something needs to be done.  The last thing we need is a state run Task Force or Commission investigating  itself.  The second to last thing we need is consultants hired by the state to write another report.  At this point, I don't even think that a review of the incidents is possible.

Any hospital in the state should be required to prospectively flag records based on violence, aggression and whether they were transferred from the correctional system.  All of the staff in those cases should make a recording of their perceptions of the antecedents, intervention and why it failed or succeeded, and the outcome.  Those cases should be reviewed on a weekly or monthly basis by psychiatrists with experience in treating severe mental illnesses and aggression.  That panel of psychiatrists should be carefully screened for conflict of interests, especially any financial conflicts of interest with the State or any other entities responsible for providing the treatment in question.

It is time to solve this problem.  Having the problems analyzed time after time by the same people who do not understand the problem and who can not possibly come up with a solution has not worked in the past 5 years and it will not work in the future.  Instead we have a state official charged with solving the problem saying that fewer psychiatrists makes sense and psychiatric expertise at the systems level is not needed as the system continues to collapse.  The system of state hospital care for patients with serious mental illnesses and aggression may not be salvageable at this point without realistic backing by the state.

A key part of the miscalculation appears to be casting psychiatrists in the role of generic technicians.  Of course these technicians would not have any understanding of patient centered care or a therapeutic alliance despite the fact that they have been writing about it for over a 50 years.  This accomplishes two goals at least at the rhetorical level.  It makes it seem like untrained administrators can address systemic issues of violence and aggression.  It also makes it seem like the only thing psychiatrists can do it prescribe medications - often to "stable" people.  Far too many errors have been made and public statements on the issues are consistent with a lack of appreciation of the problem and a complete lack of appreciation that psychiatrists are the only people professionally trained to provide this level of care.  This is by no means only limited to state systems.  These attitudes are prevalent in any hospital or clinic that is under the direction of a managed care system.

Will the problem of aggression in people with severe mental illness be addressed by arbitrary rules on patient flow and a treatment program that is flowing down from politicians and bureaucrats?  Will the problem be solved by a consensus of stakeholders?  Will the problem be addressed by new age jargon and philosophy?

I don't think so.


George Dawson, MD, DFAPA

Refs:

Minnesota Department of Human Services - Direct Care and Treatment. Plan for the Anoka Metro Regional Treatment Center. Direct Care and Treatment and Chemical and Mental Health Services Administrations. February 18, 2014

From the above document:  "Jails also count on AMRTC to take people whose criminal behavior is determined to be the result of mental illness (a new law requires that AMRTC accept referrals from jails within 48 hours of referral). Because of insufficient capacity in the service system, there are lengthy waiting lists for AMRTC beds"  (p 61).

Supplementary 1:  A previous quote from Commissioner Barry: "DHS officials say the facility no longer needs as many psychiatrists because many of the patients are stable and only require psychiatric visits once every three months. In addition, Barry said, the importance of psychiatrists at the facility has lessened over the years. Psychiatrists are just one part of the treatment team, she said. Nurses and psychologists also play an important role in patient care, and in many cases, advanced practice nurses can handle many of the tasks that used to be the responsibility of the psychiatrists, she said."

Supplementary 2:  I was unable to find any statute that described this 48 hr transfer rule.  I have asked my state representatives for assistance since it may not be a statute.  Corrected as of 12/9/2014 with the statute posted above.

Supplementary 3:  If you currently work in a non-state funded psychiatric unit and have received these transfers from correctional facilities please post your experience in the comments section below.  Feel free to post them anonymously and in a way that does not indirectly identify you or the facility that you work at.

The Shadow State Hospital System

Up until fairly recently, every psychiatrist at some point in their career was aware of a state hospital system.  The state hospitals were at one point the only available resource for long term care for most residents in a state.  They were also the facilities designated to care for people who were mentally ill and in some cases designated as dangerous to society.  That includes a population  with severe neuropsychiatric illness who have disorders that do not respond well to treatment and always represent some risk in terms of chronic aggressive behavior.  There is a population of people who are adjudicated as mentally ill but criminally culpable - that is they have failed a Not Guilty By Reason of Insanity (NGRI) defense.  This same group can be in a state facility being treated to the point where they are competent to proceed to trial or the minority group of NGRI defendants who have been adjudicated as not guilty but still need treatment before they can be released.  There is an assumption at some nonmedical level that psychopaths and people with antisocial personality disorders associated with aggression can be separated from the mentally ill persons and sent to the correctional system while some of those same definitions result in indefinite stays in specialized state mental hospitals.  The legal systems of some states designate certain forms of psychopathy or other criminal behavior a mental illness in order to allow for indefinite detention of people who are considered to have committed more heinous crimes like violent sexual offenses or sexual offenses against minors.

 At one point there were very large numbers of persons in state mental hospitals.  Two historic movements resulted in large numbers of these patients being released.  The first was the deinstitutionalization movement.  Historian Edward Shorter attributes the start of deinstitutionalization to psychopharmacology - specifically the invention of chlorpromazine that was FDA approved in 1954.  According to Shorter, the total number of patients in state and county mental hospitals declined from a high of 559,000 in 1955 to a low of 107,000 in 1980 or an 80% decrease.  In reality, many of the discharged patients did not take the medication reliably or developed side effects.  Shorter credits the "antipsychiatry movement" with providing continued impetus for state hospital discharges by suggesting that the institutions could be replaced by ""therapeutic communities" - a romanticized version of welcoming friends and neighbors clasping the mentally ill to their bosoms."  He also credits the National Institute of Mental Health with promoting this view.  The movement led to large numbers of mentally ill persons being homeless, not cared for medically or physically,  and  with dwindling resources for outpatient medical care when Community Mental Health Centers started to focus on providing psychotherapy for people without severe mental illnesses.  The Treatment Advocacy Center looks at available bed per 100,000 population as a rate.  They put the minimum acceptable figure at 50 beds/100,000.  In 1955, there were 344 beds per 100,000.  In 2005, that number had dwindled down to an average of 17/100,000 with a range of 7.1 to 50.  According to that same report 42 of 50 states had less than the minimum recommended number.

My copy of Shorter's text was published in 1997 and it says nothing about the managed care era and the effect of managed care on state hospital systems and the community systems of care that were supposed to be there to treat the deinstitutionalized.  There were few of these systems at the outset.  In the 1970s and 1980s there was the beginning of a larger community psychiatry movement and some experts began to develop systems of care to support patients who had been in state hospitals in the community.  Those systems of care were by far the exceptions rather than the rule.  When managed care took over there was no longer an asylum or a containment function in community hospitals.  People with severe mental illnesses could no longer go to short term hospitals because they were no longer able to function or they had numerous problems that were too difficult to be managed in an outpatient setting.  The only reason for hospitalization was the managed care concept of "dangerousness".  Suddenly it no longer mattered if you were manic and squandering your resources, ruining your marriage and losing your job.  Unless "suicidality" was detected or there were threats to kill somebody, a person would be discharged from the emergency department.  Not only that but, anything said in the emergency department was now taken at face value.  A patient could have been tearing up their home, obviously paranoid and threatening a neighbor.   As long as that person said he or she had no intent to harm themselves or anyone else,  they would be discharged even if the family bringing them to the hospital was horrified with that decision.  That is the state of managed care and its impact on psychiatry even to this day.  The reason is quite clear.  Several studies have shown that adequate community treatment of some persons with mental illness may be no less expensive than state hospital treatment.  It is only by providing rationed or no treatment at all that a state or health care company saves money.  That is also referred to as "cost-effective" care by the people who are rationing care.

The other interesting twist is the spin put on deinstitutionalization.  I know one of the leading proponents of this process in the 1970s and had him as an individual supervisor.  I can still recall his presentation about why he became interested in community psychiatry and was one of the leaders.  It was a single black and white photo of a large gymnasium sized room in a state hospital.  There were about a hundred men in the photo and there was room enough to have all of their cots arranged edge-to-edge across the floor.  So never let it be said that state hospitals were luxurious places to begin with.  That fact alone was one of the main reasons that psychiatrists were interested in getting patients out.  

So what is the shadow state hospital system?  At the first level it is an administrative one.  The administrative systems for any state hospital systems have always been fairly intensive.  At some point, there is a predictable scandal and a political reaction to the fact that the many of  these hospitals were mismanaged by the political system in the first place.  It is another case of politicians reinventing themselves by reforming something that they mismanaged  in the first place.  Some clear examples include each of the following:

1.  People with psychiatric illnesses used to pack state hospitals and now they pack jails and emergency departments.  One of the primary goals of the shadow state hospital is to give the public the impression that this is more humane and more effective treatment than real state hospitals run by psychiatrists.  It also effectively removes a large block of people with chronic mental illness from active treatment relationships with psychiatrists.  Any family advocates for these patients and psychiatrists themselves can unite to advocate for these patients but they are neutralized when the system is managed to allow a few 20 minute appointments with the psychiatrist per year.

2.  Rationing to the point of of the absurd is a theme that crops up on a regular basis over time.  That is true, whether you were an asylum psychiatrist seeing 500 patients or a hospital where serious injuries to staff and patients occurs.  Another goal of the shadow state hospital is to give the impression that no matter what, administrators somehow have special knowledge on how to run psychiatric services.  Nothing could be further from the truth.  The psychiatrists themselves end up jumping through a large number of administrative hoops since they are caught in this endless stream of bureaucracy and have less and less time for direct patient contact.  Bureaucrats with no appreciation of clinical medicine lack an appreciation for two critical factors in psychiatry.  Those factors are the quality of all assessments of a patient's problem depends on the time spent in direct contact with that patient.  The quality of any intervention including the prescription of medication also depends on time spent with the patient.  Together that time and relationship with the patient is the best predictor of outcome.  All administrative measures in the shadow state hospital seem to be designed to negatively impact that parameter, including the replacement of psychiatrists by "prescribers."

3.  The shadow state hospital doesn't really need psychiatrists.  Despite the fact that psychiatrists have (by far) the most training of any group of physicians or mental health professionals in hospital care and care of patients with the most serious mental illness, all of the administrative focus is the general elimination of psychiatrists.  I think it makes perfect sense from the administrative side.  If you are an administrator who is accountable to politicians or government bureaucrats - eliminating psychiatrists accomplishes two goals.  The first is taking out any professional opposition to any measures that you decide to implement from the perspective of a person with little to no training in the treatment of mental illness.  The second, is having a group of professional employees to scapegoat.  What better arrangement could there be than hiring people who are overworked to the point that they have little time left to muster any opposition to your plans and that same overworking in a dangerous environment puts them at risk for adverse events that they can ultimately be blamed for?  All of these events are the predictable outcome of people working in a split environment.

4.  Collecting data on citizens for reasons other than their psychiatric care.  To address the ongoing problem of gun violence by some of the mentally ill, many states have adopted legislation that allows a bureaucrat to collect data on people who have been committed for the purpose of putting them on a master list to prevent them from acquiring firearms.  The number of people denied in this manner is very small compared with domestic violence perpetrators or felons, but that doesn't prevent this false solution to the problem of gun violence at the cost of collecting this data.  In many states the only way to get into any existing mental health facilities is by civil commitment.  There is also a process for collecting financial data on the same population for the purpose of collecting money for the cost of hospitalization.  Is it ethically correct to forcibly collect fees from people with few resources who have been court ordered to get treatment?  I don't think so but apparently state and county governments do.

5.  Creating more administrative burdens to adequate treatment.  Some people who were previously treated in state hospitals are in foster care settings.  In Minnesota there was a recent ruling about developmentally disabled patients in a state hospital being secluded and restrained excessively.   That resulted in a long court ruling that applied to that incident and resulted in a financial reward to members of the class action suit, the closing of that hospital, and several administrative procedures that started to affect the providers of adult foster care.  In one case the administration of any "as needed" medication including sedatives for sleep, anti-anxiety medications, and antipsychotic medications - required a foster care provider to go online and complete a 7 page report.  Even a few extra doctor ordered doses of medication per week results in a tremendous paper work burden.  This burden was created for people who have been in stable foster care situations for years and who had been receiving excellent medical and psychiatric care.

6.  The prevention of violence and the care of the violent or aggressive patient in the community is a more bothersome situation.  Several years ago, a friend of mine told me that his son was involved in staffing a small group home that specialized in the treatment and support of violent mentally ill patients in their own adult foster care setting.  If the patient because aggressive, the staff would use pads to hold the patient to the floor until the aggression passed.  I was shocked to hear about this arrangement because there was no onsite supervision or training by anyone specializing in the treatment and containment of a physically aggressive person with mental illness.  Treating this behavior in a hospital setting with a well trained staff and clear support by the administration is difficult enough.  Now it seems that we have mini-facilities trying to provide some level of containment for aggression in residential buildings with a few staff on site.

7.  The use of limited state hospital resources for political purposes continues.  The best example is commitment for psychopathy or sexual offenses, both disorders that have no treatment and are not considered psychiatric disorders in most cases by the legal authorities.  How is it that people committing sexual offenses are hospitalized indefinitely and people with severe mental illnesses are refused admission to hospitals and eventually incarcerated for minor crimes?  Only through a shadow system.

8.  The large population of mentally ill persons who are continuously cycling between the emergency department (ED), very brief and ineffective stays on short term psychiatric units, and jail.  This constant churning is typically covered in the press as a reason for overcrowding of the ED, but the real travesty is that these patients never get their psychiatric and social problems resolved and that keeps them cycling in and out.  Discharging a person with a severe mental illness from a short term psychiatric unit or the ED does not solve anything for that person.  It is nothing more than an expensive time out.

9.  The family as hospital staff has always been with us but it has not been as prevalent since the 1950s or 1960s.  I can recall violent and aggressive patients cared for at home to the point that the entire home was trashed and family members and the patient in question had frequent severe injuries.  Short of that scenario, it is much more common today that a family becomes the default hospital staff in cases where a person with severe mental illness does not meet the managed care "dangerousness criteria" for admission.  That means the patient does not tell an emergency room physician or social worker that they are going to kill themselves or become aggressive.  Family members recognize the person needs supervision and monitoring 24 hours a day/7days a week.  I have really never met a family who could do that for more than a couple of days.  Of course they should never be put in that position, especially with the fees and taxes that every family pays for health care in this country.  Anybody who requires 24/7 supervision should be in the care of professional staff who can offer appropriate therapy and maintain a neutral relationship with the affected person.

10.  It is all about the money.  The war cry of managed care systems, government systems, and government systems managed like they are managed care systems is "cost effectiveness".  It has been known since the Hay Report that psychiatric and mental health systems took a disproportionate hit relative to all other areas medicine.  There has never really been an informed discussion of what  a reasonable budget for the provision of mental health services should be.   The cost of services is often impossible to find.  That is a bureaucratic recipe for transferring money somewhere else.  Even standard bureaucratic solutions like "a 5% budgetary cut across the board" will obviously hit the most marginally funded systems first and the hardest.  Those services are psychiatric services.  The Shadow State Hospital System can function as a funding source for other projects at the cost of providing treatment for persons with severe mental illness.

11.  Let's all pretend that there is a real State Hospital System.  The front end of this illusion usually starts out when a person actually meets managed care "dangerousness criteria" and the hospital case managers cannot discharge them.  In this case, the court usually assists the hospital in getting the patient out.  For example,  there used to be a system to commit patients with substance use problems to treatment.  Those patients are frequently released by courts on the basis that they "no longer do chemical dependency commitments".  In the case of severely disabled patients with mental illness, the court may ignore that standard in a state commitment statutes and release the person for not being imminently dangerous.  In both cases the patient is hospitalized for a few days longer than the 3-5 day managed care length of stay instead of being committed to a system of care.   It appears as though something has occurred but it really has not.  

The Shadow State Hospital System allows the state and its partners in private business to establish covert control over any mental health system of care - to the detriment of the professionals and patients in that system.  The exact number of administrative measures and facilities like the ones I outlined above are unknown.  Shadow systems thrive on a lack of transparency, at least until the next scandal happens.  At that point there seems to be some level of transparency, but it is always incomplete and the real story of what happened and why never seems to surface.

The real state hospitals systems were far from perfect, but it is time for medical accountability to replace government bureaucrats and the very weak standard of accountability of these bureaucrats.  Until the Shadow State Hospital System is recognized as the prime example of mismanaged care we will not be able to address the miscalculations of deinstutionalization or what Shorter called:

"....one of the greatest social debacles of our time."


George Dawson, MD, DFAPA

Ref:

1:  Shorter E, A History of Psychiatry. John Wiley & Sons. New York, 1997.


Supplementary 1:  The image used for this post is of Dexter Asylum attributed to Lawrence E. Tilley [Public domain], via Wikimedia Commons.  The original image was Photoshopped with a graphic pen filter.

Shut Down The Psychiatric Gulags - Don't Build More!

On my drive home from work yesterday, I heard an outrageous story about a judge ordering LA County jail to build 3,200 psychiatric beds to treat mentally ill inmates in that facility.  As is typical of MPR, I could not find the link today but I did find the link to this LA Weekly story , that basically brings people up to speed.  It is a typical journalistic approach with the human interest component.  In this case the human interest portion was interesting to me, because I have heard these stories hundreds of times from people I have treated who have been incarcerated with a few variations.  The most significant variations have to do with suffering acute alcohol or drug withdrawal and not being assessed or treated for that problem and not having access to maintenance medications that have proven effective for the specific mental illness.  The current plight of the mentally ill in the LA County jail system and increasing judicial pressure on the basis of rights violations for the lack of treatment led county supervisors to vote to build what was called the most expensive building project in county history.  From the article:

"That day, county supervisors ........ voted to spend nearly $2 billion on a long-sought jail to replace notorious Men's Central, a facility that federal investigators say is plagued by suicides, abusive conditions and violence. The funds will build a two-tower compound given the ungainly name "Consolidated Correctional Treatment Facility."

According to the article it will be a 4,860 bed facility,  3,260 (67%) beds of which will be dedicated to treating prisoners with mental illness.  My most recent post on the matter includes information that LA County jail has 19,386 inmates and that recent epidemiological surveys suggest that 30-45% of inmates have problems due to severe mental illness and impaired functional capacity.   That suggests that unless public policy changes, the most expensive building project in LA County could be overwhelmed by demand before it gets started.  The author in this case points out the folly of building this tower.  It is basically the folly of building any large psychiatric facility in the absence of any other infrastructure, but in this case compounded by the fact that this is in fact a jail and not a treatment facility.  There is really no evidence that the problematic aggressive or suicidal behavior will be any better in a new "two-tower compound" with the same jail atmosphere and mentality.

I have previously posted about the plight of the mentally ill being incarcerated in America and the fact that county jails are currently our largest mental institutions.  It is a basic collusion between governments at all levels and the business community to enrich corporations that have been set up to "manage" the American healthcare system.  As usual, the most vulnerable people are "cost shifted" out.  Cost shifting refers to cost center accounting that basically leads divisions within the same organization to try to save money on their budget by shifting the costs to somebody else.  In managed care systems it can lead to all kinds of distortions in care.  It also happens with outside agencies.  I was told about a situation where workers in one county actually dragged an  intoxicated patient over the county line and into another county so that patient would no longer be their  financial responsibility!  Cost shifting is the end result of these perverse incentives.

There is perhaps no better example than incarceration rather than hospitalization.  There are estimates as recent as from a few days ago that treatment and possible hospitalization may cost $20,000/year as opposed to incarceration costing $60,000/year.  In both cases the taxpayers pick up most of the tab.  The cost shifting has occurred from insurance companies and health care systems to the correctional system.  If an insurance company can dump a patient with a severe mental illness into jail, it doesn't cost them a thing.   If that same patient is hospitalized they may receive a one-time DRG (Diagnosis Related Group) payment of about $5,000 irrespective of how long the patient stays.  The hospital incentive is to get them out in 5 days whether they are stable or not to maximize profit.  When they are discharged, the patients are generally expected to go to appointments to discuss their medications.  Clinic profits on these visits are minimal but the main problem is that many of these appointments are missed - in some cases up to 50-60%.  Many of these patients lack stable housing and they frequently end up back in the emergency department and back in the hospital.  Hospitals now have bottlenecks in the emergency department and many people are discharged back to the street.  The cycle of ineffective care continues.

I can attempt a brief analysis of the problem as I watched it unfold during 23 years of inpatient practice.  I will demonstrate how things have changed to the detriment of patients with severe mental illness.  Consider the hypothetical case of Mr. A.  He has diagnoses of depression, schizophrenia and alcohol dependence.   He recently ran out of his usual medications and started drinking.  He became progressively depressed and stopped talking with his family members.  They went over to see him and noticed he has a loaded handgun on his table and was talking about shooting himself.   They called the police who came, confiscated his handgun, noted that he was acutely intoxicated and sent him to the local hospital emergency department.  How has the management of this scenario changed over the past 30 years and why?

In the early 1980s, Mr. A would have been assessed as a person who was high risk for ongoing suicidal behavior (depression, schizophrenia, alcoholism and acute intoxication) and admitted to a psychiatric unit.  The psychiatrist there would have done everything possible to stabilize all three conditions even if it meant civil commitment to a long term care institution.  The length of stay (LOS) would have been on the order of 20-30 days comparable to many current psychiatric LOS in the European Union.

By the late 1980s, a managed care company would have called the hospital or psychiatrist in charge.  They would initially demanded that the patient be discharged to a county detox facility.  They would claim that alcohol withdrawal detoxification was not a psychiatric problem, and therefore the patient does not meet their "medical necessity criteria" for inpatient hospitalization.  If that was ineffective they might say that he was no longer "acutely suicidal" or "imminently dangerous" two additional medical necessity criteria.  In the end they always win, because they just stop paying and the administrators force the clinicians to discharge the patient.  The length of stay is now down to less than 1 week and the patient may not be stable at all at the time of discharge.

By the 1990s, the patient might not even make it to the inpatient unit.  By now psychiatric departments are continuously burned by managed care companies, especially in the case of any patient who is acutely intoxicated at the time of admission.  Many have closed their doors.  Many departments have strongly suggested that the emergency departments send any intoxicated patients directly to county detox units if they are available.  The counties respond by refusing to take any patients on any intoxicants than than alcohol and even then the patient has to blow a number on a breathalyzer consistent with acute alcohol intoxication.   At any point in this process a decision can be made to just send the patient home.  There are various ways the patient can access more firearms at that point or even get the original firearm that was confiscated.  There are also various ways that the patient can end up incarcerated including going back home, drinking and getting arrested for disorderly conduct or public intoxication.  A more complicated situation occurs if the patient is intoxicated and wanders into a neighbor's home or place of business.  I have seen people end up in jail for months on trespassing charges in these situations.   And that brings us in to the 2000s where it is much more likely that a person with severe mental illness will be incarcerated than even make it to the emergency department.  In the 2000s the patient may end up stranded in the emergency department for days or sent home with a bottle of benzodiazepines to handle their own detox if they can deny that the are "suicidal" consistently enough.  There is also the mater of inpatient bed capacity.  Fewer beds are full constantly because bed capacity has been shut down due to managed care rationing and people are often released because there will be no open beds in the foreseeable future.  The LOS in many cases is now zero days, even for people with severe problems.

How did all of this happen?  How did the care of mental illness and addictions fall to such a miserable standard?  It is documented in many posts on this blog.  Professional guidelines were compromised and treatment infrastructure was destroyed by the managed care industry and the politicians who actively supported and continue to support it.  Professional organizations don't stand a chance against pro business state statutes,  commissions stacked with industry insiders, and federal legislation that protects these companies from lawsuits for interference with care.  Even a travesty as basic as prior authorization for generic drugs is unassailable.  I don't understand why these basic facts are so incomprehensible to people in the field.  Just a few hours ago, 1BOM posted a Hall of Shame of entities the original authors claim are failing people with severe mental illness.  This list completely misses the mark and is probably a good example of how deeply entrenched the mechanisms are to prevent treatment  and shift costs away from states and health care companies.

There are countless easy solutions to the problems, but the companies in power literally do not want to spend a dime.  The patient with severe mental illness can receive comprehensive community services and be maintained in their own housing at a cost of $10, 000 to $20, 000/year for clinical services.  That same patient costs corrections departments $60,000 per year.  That patient currently costs managed care companies nothing if they can transfer their care to a local state-funded Assertive Community Treatment (ACT) team.  Managed care companies incur the same cost if the patient is transferred to the correctional system.  If ACOs come to fruition and all of the chronically mentally ill are enrolled, it should be an easy matter to make the managed care companies responsible for both the costs and the patient.  A simple court order to pick up the patient from jail and stabilize them in the community could suffice.

Erecting more gulags won't work.  They are effective only for enriching health care companies that profit by denying care for those with severe mental illnesses and addictions.  They are also another hidden health care tax on the taxpayers who are already paying far too much in hidden health care taxes.




George Dawson, MD, DFAPA

Graphics Credit:  ConceptDraw Pro - this graphic was included as an example with this software.